Methods
To conduct the scoping review, we will consider the six stages recommended by Arksey and O'Malley, and Levac et al. [
25,
26]. This protocol has been registered within the Open Science Framework (Registration link:
https://osf.io/kjhzt). Besides, it is developed by following the guidance of Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) [
27] (the see checklist is provided as Additional File
1). The result will be reported in accordance with the reporting guidance provided in the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews (PRISMA-ScR) statement [
28].
Stage 1: identifying the research questions
Collaborating with researchers from Johns Hopkins Bloomberg School of Public Health (JHSPH) and Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), India, three research questions are proposed with a broader scope while having a precise aim, listed in the previous section.
Stage 2: identifying relevant literature
The literature search will include a broad range of terms and keywords related to three concepts—“integrated care model,” “primary and secondary care system,” and “low- and middle-income countries.” The primary source of evidence will be a structured literature search of five electronic databases (from 2000 to 2020): PubMed/MEDLINE, EMBASE, Scopus, Web of Science, and Global Index Medicus. The secondary source of potentially relevant material will be a search of the grey literature, including institutional websites (e.g., WHO and World Bank), Health Policy Plus, Google Scholar, and OpenGrey. Besides, hand-searching of the reference lists will be performed for selected articles and policy reports. If necessary, subject matter experts and prolific authors in the field will be contacted based on the study’s feasibility and necessity.
The review team will lead the design and implementation of the search strategy, and we will actively consult with a health information specialist [
29]. A draft search strategy for PubMed/MEDLINE is provided in Additional File
2. After implementing the search, the title and abstracts will be downloaded, and citations will be imported into Covidence systematic review software (
covidence.org). At this stage, we will remove the duplicates and organize the search records to review their titles and abstracts.
Stage 3: screening and selection procedure
We have used the “Population-Concept-Context (PCC)” framework [
30] to align our study selection process with the specific research questions mentioned in the previous section. The preliminary inclusion and exclusion criteria for the screening are presented in Table
1.
Table 1
Inclusion and exclusion criteria for the record selection process
Concept | • Integrated primary-secondary health care model | • Article lacking evidence or discussion on the primary-secondary care integration (Example: A study may report the prevalence of obesity-related comorbidity and then recommending an integrated primary-secondary health care model as a recommendation. This will be excluded during the selection process) |
Context and population | • 31 low-income countries and 47 lower-middle-income countries based on the World Bank's classificationa | |
Document type | • Peer-reviewed journal articles • Grey literature (such as policy brief or programmatic reports) • Quantitative, qualitative, mixed or multimethod research, policy analysis, methodology paper | • Chart reviews, opinion papers, case reports, editorials • Conference proceedings and posters |
Time frame | • 2000 - 2020 | |
Reporting characteristics | • Articles are written in English • Complete articles that have been published | • Article not published in English |
The review will include a wide range of documents, such as peer-reviewed publications, methodological papers, and grey literature, published in the English language from 2000 to 2020. However, we decided not to include chart reviews, opinion papers, case reports, editorials, and conference proceedings. Most importantly, to be included in the review, the document or article will need to include evidence on the primary-secondary integrated health care model in low- and middle-income countries, which we have considered as (see supplemental material Additional File
2 for further details):
The approach toward vertical integration of primary and secondary healthcare systems, which requires a set of coordinated strategies that involve streamlining the organizational arrangements, functional processes, service delivery apparatuses, clinical operations, and community-health facility interfaces—either by implementing independently or in any specific combinations—for incorporating secondary care functions within the primary care settings or vice versa, enabling upstream and/or downstream restructuring by augmenting health systems resources—within one setting or across health facilities—to provide evidence-based, people-centered and high-quality healthcare service and, simultaneously, to improve the performance of health systems.
Following these criteria, two independent reviewers will screen the title and the abstract (or executive summary) of the searched documents. For those eligible peer-reviewed journal articles and grey literature, which will appear to represent the subject of our scoping review, copies of the full documents will be obtained. Next, the reviewers will read the full document and decide to include the article/report in the review process. The research team will regularly review the result of the screening process and discuss the discrepancies. In the case of an undisputed disagreement, a senior researcher will take the role of arbitrator to resolve the issue. We acknowledge that literature search and screening is an iterative process, and we will pragmatically adapt the search criteria if necessary and reiterate the screening process [
25].
Stage 4: charting the data
Full-text articles included in the scoping review will be re-appraised, and information will be charted using a data extraction form [
30]. Focusing on the research question identified in stage one, we have developed a data extraction form to summarize the evidence from the document. The themes and variables included in the data extraction form are presented in Table
2, and the extended version of the data extraction form is provided in Additional File
2 as supplemental material.
Table 2
Summary of the data extraction form to chart the evidence
Study characteristics | Source |
Title |
Authors |
Year |
Country name |
Country type (World Bank’s classificationa) |
WHO region |
Study populations |
Study location |
Study design and methodology |
Scoping review specific | Definition of integrated care |
Typologies of integration |
Type of service integrated (if applicable) |
Health systems building blocks integrated (if applicable) |
Mechanism of integration (if applicable) |
Structure of integration (if applicable) |
Intensity of integration (if applicable) |
Organizational and operational components |
Success |
Facilitators |
Bottlenecks |
Unintended consequences |
Two distinct sets of information will be charted using the data extraction form. The first set of information is related to the characteristics of the article, which will include the source of the article, title, authors, publication year, country where the study was conducted, or the evidence was generated, country type (low-income or lower-middle-income), WHO region, study populations, study location (urban or rural), design and methodology of the study, etc.
The second set of information is specific to this scoping review which are, but not limited to, definition of integrated care, typologies of integration, type of service integrated, health systems building blocks integrated, mechanism of integration, the structure of integration, the intensity of integration, organizational and operational components of integration, success, facilitators, bottlenecks, and unintended consequences. Detailed descriptions of each of the scoping review specific thematic areas are presented in the supplementary materials of Additional File
2.
A team of two researchers will conduct the data charting process. The process will start with a pilot exercise, where the two data extractors will independently chart the data from the same five eligible articles in parallel using an initial draft of data extraction from (developed based on Table
2). A workshop will be conducted in the presence of a third senior researcher as an arbitrator to triangulate the extracted data to streamline and harmonize the data charting process between the two researchers. Next, the eligible articles will be divided among the two researchers for completing the charting process. After completing every ten articles, the senior researcher will moderate a review meeting to go over the extraction process and resolve any impending or unintended issues in the charting process. During this stage, if additional details regarding an article or report are required, we will try to reach out to the investigators for additional information while pragmatically considering the time and resources required for this process.
Stage 5: collating and reporting the results
In the fifth stage, the charted information will be summarized into thematic areas and reported in a narrative format with tables and illustrations. We will present an overview of the material included in the screening and the review process. Based on the number of articles, we will use Dedoose (
dedoose.com) to extract the emergent themes and patterns from the data if necessary. The result will be clustered and presented to explore the geographic, socioeconomic, and health system variation across the countries.
Stage 6: expert consultation
While Arksey and O'Malley suggested expert consultation as optional for scoping review [
25], we agree with Levac et al. [
26] that this stage is essential for finalizing the scoping review. We also intend to perform a consultation exercise after developing the initial report of the scoping review. This scoping review is commissioned to inform and provide pragmatic recommendations to the AB program to lead a discussion for instilling PSI models as an instrument for achieving UHC. Thus, we need to organize the result and collate the evidence of our review to be palatable for the policymakers and public health practitioners in India. We will develop a roster of researchers from JHSPH, GIZ, and other organizational networks, practitioners, and public health policymakers for this consultation process to strengthen the review [
31]. This is a critical component of our study as this part links the evidence with the ground reality of the Indian health system. Translating the finding of the review into pragmatic recommendations for adopting a PSI model is critical for this formative exercise.
Discussion
Ethical approval will not be necessary for the scoping review. The required information will be obtained from the publicly available literature on integrated health care models that have been adopted in LMICs, and no primary data will be collected. The investigators will also maintain a research log to record all necessary changes and methodological decisions taken while conducting the scoping review. Furthermore, the details of any changes made to the protocol of this scoping review will be outlined in the Open Science Framework, in addition to reporting in the final manuscript.
Before embarking on the journey to conduct this review, we have anticipated two operational challenges. Firstly, the three core concepts liked to the objective of this scoping review (“integrated care model,” “primary and secondary care system,” and “low- and middle-income countries”) are relatively broad and somehow ambiguous. We anticipated that the implementation of the search strategy would produce a considerable breadth of documents, which has possible implications on the study timeframe. Secondly, as a part of the inclusion criteria, we will include studies with a wide range of methodological variation. Though this variability will not affect the title and abstract review or full-text screening process, synthesis and collation of the wide range of evidence in a harmonized way will be a challenge.
We also want to acknowledge a few anticipated limitations of this review. While structuring this scoping review, we have decided to include the five major literature databases that encompass most health science-related articles. However, there is always a possibility of missing some relevant documents related to PSI models [
32]. We will actively try to mitigate this limitation by exploring additional databases of the grey literature. However, unlike a systematic review, developing an all-encompassing search strategy and collating all relevant studies is impossible for scoping reviews [
33]. Besides, excluding the documents that are not published in English will also lead to some study attrition. Lastly, while not a limitation, it is essential to emphasize that we will not assess the quality of the evidence during the review process or compare the robustness or generalizability of different PSI models [
24,
25,
30].
This scoping review forms a part of the overarching study to-explore the scope of PSI models under the AB Program in India. Thus, we are particularly interested in building an efficient dissemination strategy for this scoping review. The dissemination process will start with sharing the initial findings of this review with other researchers, practitioners, and public health policymakers within and beyond our organizational networks as part of the consultation exercise to enhance the review’s quality. The final report will be disseminated through a workshop involving critical national and state-level stakeholders for the AB program in India. The findings will serve as an advocacy tool for rolling out PSI for UHC in India. We will also develop publication as peer-reviewed journal articles and share the result via dissemination events such as conferences and online fora.
An integrated primary, secondary, and tertiary health care model is an essential strategy to transition toward UHC. This scoping review will inform policy decisions, legislative and financing frameworks, changes in the health service organization, use of information systems, and health teams’ orientation that will be needed to facilitate PSI in India. This study will serve as a foundation for modeling and implementing the efforts of PSI under the AB program.
Acknowledgements
We acknowledge the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), India, for financial support. We would also like to thank Welch Medical Library of Johns Hopkins University for providing instrumental support to conduct the scoping review. We also thank our collaborating Informationist from the Welch Medical Library, Donna Hesson, for her time and support.
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